Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study

OBJECTIVES

To determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual.

SETTING

A single university-affiliated teaching hospital.

PARTICIPANTS

2541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality.

RESULTS

The introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p=0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9-21) pre-BPT vs 14 days (IQR 11-22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44 hours pre-BPT (IQR 24-44) vs 23 hours post-BPT (IQR 17-30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p<0.005). There was a survival benefit at 1 year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival.

CONCLUSIONS

The introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes.

Gastrostomy placement in patients with Crohn's disease

Crohn's disease often involves the stomach, yet a permanent enterocutaneous fistula does not usually occur, after a percutaneous endoscopic gastrostomy is removed from a patient with Crohn's disease. This is because the factors that are related to the non-closure of a fistula are absent or have been treated (distal bowel obstruction, abdominal sepsis, undernutrition, poor gastric blood supply or abnormal serum levels of C-reactive protein and albumin). Gastric involvement in patients with Crohn's disease is common. Enterocutaneous fistulas from the stomach are rare. Percutaneous endoscopic gastrostomy (PEG) insertion and subsequent removal rarely cause problems in patients with Crohn's disease. Endoscopic removal of a PEG is advised in patients with Crohn's disease. Steroids may delay gastric adhesion to the anterior abdominal wall.

Attitudes to emotional expression and personality in predicting post-traumatic stress disorder

OBJECTIVES

To test hypotheses derived from a suggestion of Williams (1989) that negative attitudes towards emotional expression act as a predisposing or maintaining factor for post-traumatic stress reactions following a traumatic event.

DESIGN

The study employed a prospective design in which attitudes to emotional expression, the 'Big Five' personality factors (Costa & McCrae, 1992a) and initial symptoms and injury severity within 1 week of a road traffic accident were used to predict the development of post-traumatic stress disorder 6 weeks post-accident.

METHOD

Sixty victims of road traffic accidents randomly selected from attenders at a large A&E department were assessed by questionnaire and interview. Measures comprised a 4-item scale relating to emotional expression, standardized scales for intrusion and avoidance features of traumatic experiences, and for anxiety and depression and the NEO-FFI Five Factor Personality Inventory. Forty-five of these participants responded to a postal questionnaire follow-up. In this survey the battery was repeated and also included a self-report diagnostic measure of post-traumatic stress disorder (PTSD).

RESULTS

The percentage of the sample meeting DSM-IV diagnostic criteria for PTSD at 6 weeks post-trauma was 30.8%. A small but significant relationship was found for negative attitudes to emotional expression at 1 week to predict intrusive symptoms and diagnosis at 6 weeks, over and above the independent relationships of initial symptoms, initial injury severity, personality and coping. The emotional expression measure was largely stable between the two points of measurement. More negative attitudes to emotional expression were related to less openness, extraversion and agreeableness personality domains.

CONCLUSIONS

Some support for the hypotheses was found in relation to the development of PTSD and for the status of attitudes to emotion as a stable trait related to personality factors. The potential importance of attitudes to emotional expression in therapy and other work is discussed.